​Good morning and welcome to the Boardroom of the National Transportation Safety Board.

I am Robert Sumwalt, and I’m honored to serve as the Chairman of the NTSB. Joining us are my colleagues on the Board: Vice Chairman Bruce Landsberg, Member Earl Weener, Member Bella Dinh-Zarr, and Member Jennifer Homendy.

Today, we meet in open session, as required by the Government in the Sunshine Act, to consider the fire on board the small passenger vessel Island Lady near Port Richey, Florida, on January 14, 2018.

The Island Lady was operated by Tropical Breeze Casino Cruz as a shuttle to and from their casino boat, the Tropical Breeze I. On the outbound journey, the captain received a high-temperature alarm on the port engine’s jacket water system. In response, he put the port engine in neutral and, relying on the fully functional starboard engine, he turned the vessel back toward shore.

Soon after, however, thickening smoke enveloped the Island Lady. The captain deliberately beached the vessel so the people on board could be evacuated to shallow water. Fire eventually engulfed the main deck and burned the vessel down to the waterline, and it was declared a constructive total loss.

The passengers, crew, and other employees on board were able to evacuate by jumping off the Island Lady, but fifteen of them were injured. Tragically, one passenger died hours later in a local hospital.

On behalf of my colleagues on the Board and the entire NTSB staff, I would like to extend my sincerest condolences to the family and friends of the passenger who was lost. Furthermore, let me wish those who were injured the fullest possible recovery.

The sole purpose of this investigation has been to learn from what happened, to prevent fires like this one from happening again.

Today’s presentations will tell the story of the fire in detail: how and where it began, the captain’s and crew’s responses to secure the safety of the vessel’s passengers, and the maintenance practices that created opportunities for this fire to start and spread. We will also discuss the Island Lady’s condition before the fire.

But in addition to our findings in this investigation, we will consider this Board’s previous experience with this very company after a 2004 fire on board another vessel – in virtually the exact same location.

After that earlier fire, the NTSB issued recommendations regarding preventive maintenance and firefighting training for crewmembers. The company agreed to implement these recommendations, but today we will discuss whether what they did was enough.

After the 2004 fire, we also made or reiterated companion recommendations to the U.S. Coast Guard. Was the Coast Guard’s response to these recommendations adequate?

Crewmembers on board the Island Lady were not only untrained in firefighting; except for the captain, none of them had any formal marine training.

We will discuss the captain’s decision to turn back toward the boarding dock upon receiving the high-temperature alarm—rather than the potentially disastrous alternative of continuing out to sea.

However, we will also discuss why the captain left the port engine running, even in neutral, once he realized it was overheating.

And of course, we will discuss how to prevent such a fire from happening again. The latent circumstances that we will discuss today might be repeating themselves elsewhere in small passenger vessels as we speak.

All over the country this morning, crew training is either being conducted or it is being neglected. Vessels are being made safer by preventive maintenance, or their safety is being left to chance. Manufacturers’ manuals are being followed or disregarded. Warning signs are being followed-up on until their cause is known, or they are being ignored.

Safety isn’t something you have -- it’s something you do. Are we requiring vessel operators to do it?

Today, the NTSB staff will briefly present the most pertinent facts and analysis found in the draft report. Our public docket, available at www.ntsb.gov, contains more than 1,200 pages of additional information, including photos, interviews, maintenance forms and inspection records.

Staff has pursued all avenues in proposing findings, a probable cause, and recommendations to the Board.

The order of today’s meeting will be that staff will present a topic-by-topic summary of the investigation.

We on the Board will then question staff. We will also propose and vote on any amendments necessary to ensure that the report as adopted truly provides the best opportunity to enhance safety.

Now, Deputy Managing Director Sharon Bryson, if you would kindly introduce the staff.